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CITY OF PRIOR LAKE PLUMBING PERMIT Date Recd
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rA'NES°
1. Blue File I PERMIT NO. I
3. Yell City �.�. /ZZ.
(Please type or print and sign3. Yellow Applicant
at bottom)
ADDRESS
ZONING(office use)
/5?/? 6< )'n 6oro /fir Aff.
LEGAL DESCRIPTION(office use only)
LOT BLOCK ADDITION PID
OWNER •/
(Name) �`t t l o(
I /L-'`'/� (Phone) t0 1� —a5)— �4 90
(Address) 15--3 / 3 E_- ? -) o ry l/ Afi
APPLICANT
(Name) 1- )r") `--
/ (Phone) V95-1-WY%..i c�-
L
(Address).—," !Z7 ?2D A ,Mq/Gop ,S5-771
(Address) (City)
(Zip Code)
(Contact Person) LiNb13 &Clow (Phone) 95 4- yS-`/W9'
9'
APPLICANT SIGNATURE DATE A,.-/-41/f_.
APPLICANT PLEASE COMPLETE BELOW
Quantity Type of Fixtureuanti
Q tY Type of Fixture
Bath Tub with or without shower Rough-ins
Dishwasher I Water Heater
Floor Drain Water Softener
Lavatory(Bathroom Sink) Stand Pipe(Washing Machine)
Laundry Tray(1 or 2 compartment sink Sewage Ejector
Shower Stall Backflow Assembly
Sinks Backflow Assembly Test
Bar Sink Lawn Sprinkler
Water Closet(Toilet) Other
FE
Industrial,Commercial&Multi-family 1%of job cost with$49. 50 miE nimum
Residential,New One&Two-Family $149.50
Residential,Additions&Alterations $49.50
Estimated Cost $ 401 yU) Building Permit#
PLUMBING PERMIT FEE $ 10.
STATE SURCHARGE $ $1.00
(Office Use Only) TOTAL PERMIT FEE $ S� f V
This Application Becomes Your Building Permit When Approved Paid
5�,�-D Receipt No. 3�6 c
Building Official Date By
Date /0., L5
24 hour notice for all inspections(952)447-9850
4646 Dakota Street S.E.,Prior Lake,Minnesota 55372